* 1. STOP: This copy of the survey is for student use only, for reflecting on goals and progress over the course of the semester. If you are a supervisor who is attempting to complete this evaluation at the end of the semester, PLEASE DO NOT USE THIS FORM. Your student's professor emails a link toward the end of the semester for the actual evaluation.

Thank you for supervising a Human Services intern this semester. Your honest feedback is critical to the learning process.

* 2. Student Intern's Initials (first and last initials)

* 3. On-site Supervisor (your full name)

* 4. Name of Agency

* 5. Semester (Spring, Summer, or Fall) and year

* 6. Course (HS 280, 281, 380, 481)

* 7. WU Seminar Instructor's Name

* 8. Please rate your student intern's performance when completing the following tasks under appropriate supervision.

  Problematic Underdeveloped for internship level Developing adequately for internship level Well developed for internship level Ready for professional practice N/A
Describes history of agency, services it provides, and population served.
Applies the mission of the agency in internship work.
Identifies strengths of consumers, agency, and/or community.
Works effectively with people of diverse backgrounds.
Demonstrates a social justice orientation.
Advocates for consumers who face unjust barriers.
Demonstrates an understanding of the consumer from a "whole person" integrative wellness perspective.
Applies effective prevention skills.
Applies effective intervention skills.
Applies effective program evaluation skills.
Uses effective interpersonal skills (e.g. deep listening, establishing rapport, self-awareness, etc.).
Practices effective professional skills (e.g. accountable, goal-oriented, reliable, collaborative, etc.)
Seeks supervision appropriately.
Receives and uses feedback well.
Engages in effective oral communication.
Engages in effective written communication.
Adheres to professional ethical standards.

* 9. Please elaborate on special strengths this student has shown.

* 10. Please describe areas of needed growth.

* 11. Please provide any other comments about the student's performance.

* 12. Assign a grade for the student's overall fieldwork performance based on your expectations for interns:

* 13. If your student is completing this internship as part of the requirements for seeking the Licensed Addictions Counselor status in Kansas, please complete the following questions. Otherwise, you are finished with this survey. Otherwise, scroll down to the bottom to "sign" the form, access instructions for printing, and close the program.

Please rate the intern's skills when performing the following tasks under appropriate supervision:

  Problematic Underdeveloped for internship level Developing adequately for internship level Well developed for internship level Ready for professional practice N/A
Participates in screening process to determine eligibility for treatment/referral.
Participates in intake process, including intake documentation.
Helps in orienting clients to the program (e.g. goals, rules, treatment costs, client rights).
Participates in assessment procedures to determine strengths, problems, and other needs.
Participates in collaborative and integrative treatment and recovery planning.
Participates in individualized counseling sessions to assist clients in achieving objectives.
Co-facilitates group counseling sessions to assist clients in achieving objectives.
Engages in case management activities to coordinate services.
Participates in appropriate crisis intervention strategies.
Provides educational sessions to clients, families, community groups, or other important stakeholders.
Participates in referral process, showing understanding of community resources.
Engages in report and record keeping related to assessment, treatment, and recovery planning.
Engages in consultation with agency staff and outside professionals to assure quality care.

* 14. Note: If you want to print out a copy of this survey, please try to do so BEFORE you click the "done" button. Once you submit the survey, it will disappear from your screen. To print, try right clicking and choosing print, or choosing print from the file menu. If this doesn't work, we apologize. The student can request a copy of the evaluation from his/her seminar instructor if you need a copy for your files.

By typing my first and last name in the following box, I acknowledge that my responses are an accurate reflection of my perceptions of the student's performance and that I have reviewed this evaluation with the student.